Anatomy Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail 2

Inflammation or infection of the pancreas Normally digestive enzymes secreted by the pancreas are not active until they reach the SI. When the pancreas is inflamed, the enzymes attack and.damages the tissue that produce them 2 types: 1. Acute Pancreatitis 2. Chronic Pancreatitis 3 What is Pancreatitis?

Acute Pancreatitis 4

Definition and Incidence Inflammatory disease with little or no fibrosis. Initiated by several factors: 90% of acute pancreatitis is secondary to acute cholelithiasis or ETOH abuse Develop additional complications 300,000 cases occur in the united states each year leading to over 3000 deaths. 5

Etiology: (GET SMASHED) G: Gallstone E: Ethanol T: Trauma S: Steroid M: Mump A :Autoimmune S: Scorpion bits H: Hyperlipidemia E: ERCP D: Drugs 6

Clinical Presentation Abdominal pain – Epigastric – Radiates to the back – Worse in supine position Nausea and vomiting Garding Tachycardia, Tachypnea, Hypotension, Hyperthermia Elevated Hematocrit & Pre renal azotemia Cullen's sign Grey Turner's sign 7

Grey Turner sign Cullen’s sign 8

Diagnosis: Biochemical – serum amylase Nonspecific Returns to normal in 3-5 days Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity – Urinary amylase – P-amylase – Serum Lipase – CBC Increased Hb Thrombocytosis Leukocytosis – Liver Function Test Serum Bilirubin elevated Alkaline Phosphatase elevated Aspartate Aminotransferase elevated 9

Assessment of Severity Criteria 1.ranson 2.APACHE-2 Biochemical Markers Computed Tomography Scan 10

Ranson Criteria Criteria for acute gallstone pancreatitis Admission – Age > 70 – WBC > 18,000 – Glucose > 220 – LDH > 400 – AST > 250 During first 48 hours – Hematocrit drop > 10 points – Serum calcium < 8 – Base deficit > 5.0 – Increase in BUN > 2 – Fluid sequestration > 4L 11 <2 pos sign: mortality rate is pos sign: mortality rate is 10 to 20% >7 pos sign: mortality rate is >50%

CT scans of normal kidneys and pancreas Spleen L Kidney R Kidney A Stomach Liver V Pancreas 12

Pancreatic Necrosis 13

Treatmaent of Mild Pancreatitis Pancreatic rest Supportive care – fluid resuscitation – watch BP and urine output – Pain Control – NG tubes and H 2 blockers or PPIs are usually not helpful Refeeding (usually 3 to 7 days) If: – Bowel Sounds Present – Patient Is Hungry – Nearly Pain-free (Off IV Narcotics) – Amylase & Lipase Not Very Useful 14

Treatment of Severe Pancreatitis Pancreatic Rest & Supportive Care – Fluid Resuscitation – may require 5-10 liters/day – Careful Pulmonary & Renal Monitoring – ICU – Maintain Hematocrit Of 26-30% – Pain Control – PCA pump – Correct Electrolyte Derangements (K +, Ca ++, Mg ++ ) Contrasted CT scan at hours Prophylactic antibiotics if present Nutritional support – May be NPO for weeks – TPN 15

Complications Local – Phlegmon, Abscess, Pseudocyst, Ascites – Involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction Systemic – A. Pulmonary : pleural effusions, atelectasis, hypoxemia, ARDS. – B. Cardiovascular : myocardial depression, hemorrhage, hypovolemia. – C.Metabolic : Hypocalcemia,hyperglycemia,Hyperlipidemia,coagulopathy – D. GI Hemorrhage – E. Renal – F. Hematologic – G. CNS – H. Fat necrosis 16

Management 17

Chronic Pancreatitis 18

Definition and Prevalence Defined as chronic inflammatory condition that causes irreversible damage to pancreatic structure and function. Incurable 5 To 27 Persons Per 100,000 19

Etiology Alcohol, 70% Idiopathic (including tropical), 20% Other, 10% – Hereditary – Hyperparathyroidism – Hypertriglyceridemia – Autoimmune pancreatitis – Obstruction – Trauma – Pancreas divisum 20

Classification: 1. calcific pancreatitis 2. obstraction pancreatitis 3. inflammatory pancreatitis 4. auto immune pancreatitis 5. asymptomic fibrosis 6. tropical pancreatitis 7. hereditary pancreatitis 8. idiopathic pancreatitis 21

Signs and Symptoms Steady And Boring Pain Not Colicky Nausea Or Vomiting Anorexia Is The Most Common Malabsorption And Weight Loss Apancreatic Diabetes 22

Laboratory Studies Tests for Chronic Pancreatitis I. Measurement of pancreatic products in blood A. Enzymes B. Pancreatic polypeptide II. Measurement of pancreatic exocrine secretion A. Direct measurements 1. Enzymes 2. Bicarbonate B. Indirect measurement 1. Bentiromide test 2. Schilling test 3. Fecal fat, chymotrypsin, or elastase concentration 4. [ 14 C]-olein absorption III. Imaging techniques A. Plain film radiography of abdomen B. Ultrasonography C. Computed tomography D. Endoscopic retrograde cholangiopancreatography E. Magnetic resonance cholangiopancreatography F. Endoscopic ultrasonography 23

24 Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitis Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. The pancreatic duct and its side branches are irregularly dilated

CT features 25 The cardinal CT features of CP are pancreatic atrophy, calcifications, and main pancreatic duct dilation.

ERCP 26 ERCP is a highly sensitive radiographic test for CP.

MRCP 27 MRCP allows a noninvasive alternative to ERCP for imaging the pancreatic duct.

EUS EUS is a minimally invasive test that allows simultaneous assessment of ductal and parenchymal structure. 28

Treatment Analgesia Enzyme Therapy Antisecretory Therapy Neurolytic Therapy Endoscopic Management Surgical Therapy 29

Complications Pseudocyst Pancreatic Ascites Pancreatic-Enteric Fistula Head-of-Pancreas Mass Splenic and Portal Vein Thrombosis 30

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Management 32

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